ABTRACT By Group D Background : Dentoalveolar trauma is a trauma involving the teeth, the alveolar portion of the maxilla and

mandible, and the adjacent soft tissues. It causes mild until severe effect and may lead to several complications that disturbs the daily activity, such as opening and closing mouth. Purpose : to know the effect of dentoalveolar trauma and the treatment. Discussion : dentoalveolar trauma is able to cause the destruction of soft tissue caused by impact which leads to ulceration, dentoalveolar fracture, luxation, even avulsion. Severe trauma on tooth may lead to the alteration of the tooth, from vital to non-vital, caused by the vascularization rupture and pulp tissue innervation. Those effects must be treated well to normalize the dentoalveolar function, especially the stomatonagtic function and esthetic which is by normalizing the occlusion just like before trauma and fixing the luxated tooth and dentoalveolar fracture. Treatment is done based on the emergency level of wound or tissue destruction itself. In complex dentoalveolar trauma, many complications need longer treatment, especially to normalize the periodontal tissue function which usually is destructed by the trauma. To treat the traumatic tooth, clinician need to pay attention to the periodontal tissue condition. For example, treatment on non-vital tooth which need to wait for the formation of connective tissue so that it is stable enough to be treated by endodontic treatment. Conclusion : Treatment of dentoalveolar traumatic patient may involves many fields, such as oral surgery, conservation, periodontology, and oral medicine. The prognosis of treatment is influenced by the right anamnesis, patient, the right treatment plan from those fields, and the right treatment procedure. Keywords : dentoalveolar trauma, avulsion, luxation, ulceration, dentoalveolar fracture

CHAPTER 1 INTRODUCTION 1.1 Background In daily life, there are many cases of oral health problem. The oral health problem can be simple or complex. Dentist has to know which therapy is appropriate in every case of oral health problem. Patient with complex symptoms of dental and oral problems needs complex treatment plans that must be considered well. Case of this first scenario is 22 years old man patient come to RSGMP Universitas Airlangga clinic with lesion and swelling on his lips because he has fallen from his motorcycle one day before. Lesion on his lips is irregular with 1 cm size and feels pain. An upper right incisive is detached and three of right and anterior teeth are loose, changing position, with bleeding. Detached tooth were brought by patient and wrapped by handkerchief. Patient can open and close his mouth well. Radiographical view shows that there is radiolucent on tooth 11 sockets and radiolucent line on alveolar bone interdentally 21 tooth areas. 11 Tooth is edentulous. There is periodontal space on 12, 21, 22, teeth. Observation by vitality test shows that 21 and 22 teeth are not vital. The patient looks sluggish , but his body temperature is normal. His blood pressure is 120/80. After knowing sign, symptoms and additional information of patient from anamnesis and clinical observation, a dentist should know the appropriate therapy to the patient. The therapy can involve some fields from dentistry, example radiology, oral surgery, oral medicine, periodontics, conservative dentistry, and prosthodontics. In this case, dentist should consider the priority of therapy that will be given in order to successful therapy. 1.2 Learning Issue 1.2.1 What is the diagnosis of this patient? 1.2.2 What kind of medicine that appropriate for this patient? 1.2.3 What is the appropriate dental therapy for this patient? 1.3 Purpose 1.3.1 To identify oral soft tissue abnormalities.

1.3.2 To determine the diagnosis and treatment plan regarding periodontal disorders. 1.3.3 To understand the identification, etiology, and diagnosis and treatment plans in case of tooths crown damage and pulp tissue abnormalities. 1.3.4 Capable of handling cases in oral surgery clinic. 1.3.5 To know and understand the condition of patients who require extended care in the field of Prosthodontics. 1.3.6 Capable to determine the appropriate kind of radiographic to support the diagnosis and treatment planning and post-treatment evaluation. 1.3.7 Capable to determine the kinds of drugs that can be used in case of emergency. 1.4 Benefit 1.4.1 Able to identify the etiology, diagnosis and treatment plans of this case 1.4.2 Able to understand the governance of therapy based on priority conditions for treatment of clinical cases in the field of dentistry

CHAPTER 2 LITERARY REVIEW 2.1 Oral Traumatic ulceration 2.1.1 Definition Ulceration is a breach in the oral epithelium, which typically exposes nerve endings in the underlying lamina propria, resulting in pain or soreness, especially when eating spicy foods or citrus fruits. Patients vary enormously in the degree to which they suffer and complain of soreness in relation to oral ulceration. It is always important to exclude serious disorders such as oral cancer or other serious disease, but not all patients who complain of soreness have discernible organic disease. Conversely, some with serious disease have no pain. Even in those with detectable lesions, the level of complaint can vary enormously. Some patients with large ulcers complain little; others with minimal ulceration complain bitterly of discomfort. Sometimes there is a psychogenic influence (Scully et al., 2005). Clinical Presentation: a. Tender to very painful b. Ulcer with yellow, fibrinous center and well-defined margins c. Inflammatory/erythematous periphery Traumatic ulcers are common oral lesions, and can be caused by a sharp or broken tooth, rough fillings, dental instruments, biting, denture irritation, sharp foreign bodies, etc (Laskaris, 2006). 2.1.2 Etiology Traumatic ulcers are common oral lesions, and can be caused by : a. a sharp or broken tooth b. rough fillings c. dental instruments d. biting e. denture irritation f. sharp foreign bodies g. Accidental/functional or factitious injury (Laskaris, 2006).

Traumatic ulcers resulting from a physical injury are probably the most common form of oral ulceration. Chronic ulcers associated with mechanical trauma are often found on the buccal mucosa, the labial mucosa of the upper and lower lips, and the lateral border of the tongue, all sites that may be injured by dentition. Lesions of the gingiva and mucobuccal fold may occur from other sources of irritation, such as tooth-brushing, which can create linear erosions along the free gingival margins, eventually associated with areas of hyperkeratosis (Compilato, et. al, 2009). 2.1.3 Manifestation There is a bimodal age distribution with one group in the first 2 years of life, where lesions are associated with erupting primary dentition. The second group is in adults in the fifth and sixth decades (Scully et al., 2005). 2.1.3.1 Minor aphthous ulcers Minor aphthous ulcers (MiAU; Mikulicz Ulcer) occur mainly in the 10 to 40-year-old age group, often cause minimal symptoms, and are small round or ovoid ulcers 2-4 mm in diameter. The ulcer floor is initially yellowish but assumes a greyish hue as healing and epithelialisation proceeds. They are surrounded by an erythematous halo and some oedema, and are found mainly on the non-keratinised mobile mucosa of the lips, cheeks, floor of the mouth, sulci or ventrum of the tongue. They are only uncommonly seen on the keratinized mucosa of the palate or dorsum of the tongue and occur in groups of only a few ulcers (one to six) at a time. They heal in seven to 10 days, and recur at intervals of one to four months leaving little or no evidence of scarring (Scully et al., 2005).

Figure 2.1: Minor aphthous ulcers.

2.1.3.2 Major aphthous ulcers Major aphthous ulcers (MjAU; Suttons Ulcers; periadenitis mucosa necrotica recurrens (PMNR)) (Figs 8 and 9) are larger, of longer duration, of more frequent recurrence, and often more painful than minor ulcers. MjAU are round or ovoid like minor ulcers, but they are larger and associated with surrounding oedema and can reach a large size, usually about 1 cm in diameter or even larger. They are found on any area of the oral mucosa, including the keratinised dorsum of the tongue or palate, occur in groups of only a few ulcers (one to six) at one time and heal slowly over 10 to 40 days. They recur extremely frequently may heal with scarring and are occasionally found with a raised erythrocyte sedimentation rate or plasma viscosity.

Figure 2.2: Major aphthous ulcers.

2.1.3.3 Herpetiform Ulceration Herpetiform Ulceration (HU) is found in a slightly older age group than the other forms of RAS and are found mainly in females. They begin with vesiculation which passes rapidly into multiple minute pinhead-sized discrete ulcers (Fig. 10), which involve any oral site including the keratinized mucosa. They increase in size and coalesce to leave large round ragged ulcers, which heal in 10 days or longer, are often extremely painful and recur so frequently that ulceration may be virtually continuous (Scully et al., 2005).

Figure 2.3: Herpetiform Ulceration.

2.1.4 Management/Therapy The treatment of oral ulceration due to chemical trauma principally requires identify cation and removal of the toxic agents. Most chemical burns are characterised by mild to moderate tissue damage that heals spontaneously within seven to days without scarring, thus only palliative and symptomatic treatment such as gentle plaque control and rinsing with a topical anaesthetic is required. In instances of more severe tissue damage, non-potent topical corticosteroids (eg triamcinolone) in a protective vehicle of carboxymethylcellulose may be helpful. A bland diet can also be benefi cial. Lesions occurring after extensive exposure to strong caustic agents may require local debridement and antibiotic therapy (Gilvetti, et. al, 2010). 2.2 Dentoalveolar fracture 2.2.1 Definition A Dentoalveolar fracture or dentoalveolar injury (DAI) is any injury related to the tooth or tooth-supporting structures (gingiva, periodontal ligament and alveolar bone) (Soukup J.W et al, 2012). Traumatic dentoalveolar injuries represent the most serious oral health problem among children and adolescents because of their major aesthetic, functional, psychological, and economic consequences. Tooth avulsion is a type of traumatic dentoalveolar injury in which the tooth is totally displaced from its socket. Traumatic teeth avulsion injuries (TTAIs) represent 16% of all traumatic dental injuries and an even greater percentage of those among children because of falls, fight and car accidents, and sport activities occurring between the ages of 7 and 9 years, the time when the permanent incisors are erupting (Ulusoy et al, 2012). Dentoalveolar traumas are observed and treated in dental clinics. Their severity depends on the energy of impact and direction of the causal agent, as well as on the resistance of the tissues surrounding the traumatized teeth, which are more susceptible at the anterior region, along with immunological factors, particularly in cases of avulsion and replantation. Situations such as car, sports and working accidents, and falling are the most common reasons for dental traumatism (Farinuk et al, 2010).

The most affected teeth were the permanent maxillary central incisors, accounting for 53.2% of cases, which exhibited higher occurrence of coronal fracture, concussion/subluxation, and avulsion. Some epidemiological studies are conducted at hospitals, whereas others are conducted at Pediatric Dentistry clinics. The present study was conducted at a specialized facility that treats only patients with dental trauma. This dentoalveolar trauma care service was created due to the gap existing in this type of care, especially concerning healthcare to the poor population (Farinuk et al, 2010). The frequency and causes of dentoalveolar trauma should be investigated for identification of risk groups, treatment demands and costs in order to allow for the establishment of effective preventive measures that can reduce the treatment duration and costs for both patients and oral health services (Farinuk et al, 2010). 2.2.2 Classification There have been numerous attempts to classify the variety of injuries that can affect the dentoalveolar structures. The American Veterinary Dental College has proposed a classification system that classifies increasing degrees of trauma to the tooth (AVDC 2010). However, the AVDC system does not address conditions in which the tooth has been displaced from its supporting alveolus (socket). Nor does it address fractures to the supporting alveolar bone. The most up-to-date and inclusive classification of DAI for humans fulfills the need to clearly define tooth displacement injuries and alveolar bone fractures (Soukup J.W et al, 2012). The type of DAI sustained was classified as: (1) dental concussive injury (clinical or radiographic evidence of tooth non-vitality in the region of trauma at the time of initial treatment or at the time of follow-up treatment up to one year after the injury); (2) crown fracture ( pulp exposure); (3) root fracture (crown fracture); (4) displacement (subluxation, luxation, intrusion and extrusion); (5) avulsion and (6) trauma to unerupted permanent tooth bud (Fig 1). The DAIs were also classified as either severe or non-severe. For the purposes of this study, root fracture, displacement and avulsion injuries were considered severe and dental concussion, crown fracture and trauma to the permanent tooth bud were considered non-severe. (Soukup J.W et al, 2012)

Figure 2.4: Classification of dentoalveolar injuries adopted by the International Association of Dental Traumatology (Andreasen and others 2012).

Luxation injuries are widely described in the primary dentition, as they are related to the resilience of the alveolar bone and the supporting structures in young children. Avulsion occurs in a prevalence varying from 7% to 13% in the primary dentition and children aged 48-60 months are the most affected (Silva Assuncao et al, 2012). Maxillary incisors are the teeth most affected by avulsion because their normal labial projection relative to that of the mandibular incisors makes them more susceptible to direct facial trauma. Moreover, the lack of resilience of the periodontal ligament and the low mineralization of the bone surrounding erupted teeth among children aged 79 provide minimal resistance to frontal impact. The prognosis of avulsed teeth is inevitably affected by appropriate emergency

management. Studies have shown immediate replantation to be the most appropriate treatment for avulsed permanent teeth. When replantation is not feasible, correct handling and maintenance of avulsed teeth in a suitable storage medium may help to secure successful long-term outcomes (Ulusoy et al, 2012).

2.2.3 Etiology Accidents within and around the home have been reported as being the major source of injury to the primary dentition, while accidents at home and school accounted for most injuries to the permanent dentition. Table 2.1 indicates there is some variation between studies and countries regarding the predominant causes of dental trauma, although accidents due to falls appear to be the most common factor in both primary and permanent dentitions. Accidents as a result of sports, violence and road traffic accidents were also common causes of dental trauma. 2.2.3.1 Injuries The number, type and severity of dental injuries per patient differ according to the patient age and the cause of the accident. Uncomplicated crown fracture without pulp exposure. However, subluxations and complete luxations were the most frequently occurring injuries in two hospital studies, particularly in the primary dentition. Displacement (luxation) of teeth has occurred more frequently in the younger age groups studied (Bastone et al., 2000). Some authors have indicated that the supporting structures in the primary dentition are resilient, thereby favouring dislocations rather than fractures. The maxillary central incisors were the most frequently injured teeth in all studies for both the primary and secondary dentitions. The second most frequently injured teeth were maxillary lateral incisors in all studies except that by Forsberg and Tedestam18 where mandibular central incisors were the second most frequently injured teeth (Bastone et al., 2000). The number of injuries per patient has varied from between 1.1 and 2.0, but this variation could have been influenced by the actual injuries being recorded, the classification used and the type of study location. The two Australian studies by Liew and Daly and Martin et al., conducted in all age groups from after hours dental clinics, reported more severe injuries to older patients and involved more teeth per patient than had been found in the Australian private practice study by Davis and Knott. The number of injured teeth per patient also varied between countries and sites of the studies. The type of study centre also affected the frequency of multiple injuries per person. One tooth was more frequently injured

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than multiple teeth in most prospective studies conducted at school dental services and general clinics. Those studies conducted in hospital casualty departments and after hours clinics have observed injuries to one and two teeth in equal proportions or two teeth more frequently than one. This may be a function of people experiencing more severe injuries after hours and it may also indicate that people attend hospitals rather than dental clinics for more severe injuries.
Table 2.1: Causes, types, and dental locations of traumatic injuries (Bastone et al., 2000).

2.1.2 Predisposing and risk factors An important predisposing factor reported for dental trauma was a large maxillary overjet and incomplete lip closure. Galea observed that the severity of injuries appeared to increase when there was an associated injury to the lower lip, while a third of the accidents occurred in subjects with some form of malocclusion. Female subjects with prominent maxillary incisors and incompetent lip closure often had multiple injuries to the supporting structures of the teeth. Burden observed that subjects with an overjet greater than the normal range (0-3.5 mm) were significantly more likely to have received an injury to the maxillary

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incisors. It also appeared that the prevalence of dental trauma in females increased as overjet increased. Dearing and Hunter et al. also observed a significant difference in the frequency of fractured incisors between patients with an increased overjet. Increased overjet, however, may not play an important role when trauma is sustained via contact or collision sports, as was demonstrated in a case-control study by Stokes et al. It should be noted, however, that there were only 36 cases and controls in this study. Competent lip coverage was also an important predictor of dental trauma. Burden observed that children with inadequate lip coverage were at greater risk of dental trauma, regardless of their overjet size. Hunter et al., however, did not observe an increased frequency of dental trauma with incompetent lip closure, particularly in females. Hamilton et al. observed that significantly more children in the lower socio-economic groups received injuries compared with the higher socio-economic brackets, while Onetto et al. observed that a high percentage of patients receiving injuries had suffered previous dental trauma. Another important factor found to increase the risk of dental trauma while playing sports was the lack of a properly fitted mouth guard and/or faceguard. The value of mouth guards may be demonstrated by Lee-Knight et al. who reported that none of the athletes who sustained dental injuries in the Canada Games was wearing a mouth guard. Johnsen and Winters46 suggest that many dental injuries can be avoided by informing the population of the importance of these protective devices whilst playing sport. Jolly et al. observed that when a mouth guard was not worn during football games, the likelihood of a fractured or avulsed tooth was at least twice that of when a mouth guard was worn. 2.2.4 Management/Therapy DTIs are usually a combination of trauma to the soft tissues, teeth, and their supporting tissues (dental polytrauma) (Martins WD et al., 2004). The management of these injuries is categorized individually for descriptive purpose only.

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2.2.4.1 Enamel infraction As a rule, infractions do not require treatment. However, in case of multiple infraction lines, the enamel surface is sealed with an unfilled resin to avoid the uptake of stains from tobacco, food, drinks, or other liquids (Andreasen F et al., 2007). Uncomplicated crown fracture For small fractures confined to enamel, rough margins and edges can be smoothed. For larger fractures exposing dentin, treatment strategy implies the application of glass-ionomer cement to the deepest dentin layer and permanent restoration using a dentin bonding agent and composite resin to complete the hermetic seal against bacterial irritant, which is more critical to pulpal healing (Andreasen F et al., 2007). The benefit of calcium hydroxide (CaOH) liner is questionable, because it has been indicated that CaOH disintegrates beneath dental restorations with time, consequently compromising the pulpal healing. Reattachment of the crown fragment and laminate veneers are other alternatives that can be considered (Andreasen F et al., 2007). Whatever treatment is decided, it is essential that the crowns anatomy and occlusion be restored immediately to prevent labial protrusion of the fractured tooth, drifting or tilting of adjacent teeth into the fracture site or over eruption of opposing incisors (Andreasen F et al., 2007). 2.2.4.2 Complicated crown fracture Treatment decisions for primary teeth are based on life expectancy of the traumatized tooth and vitality of the pulpal tissue. Pulpal treatment alternatives are pulpotomy, pulpectomy, or extraction. In young permanent teeth and immature developing teeth, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy (Cvek pulpotomy) and bacteria-tight coronal seal. While in mature teeth, pulpal treatment alternatives are direct pulp capping, partial pulpotomy, and pulpectomy depending on the exposure size and the time elapsed between accident and treatment. In extensive crown fractures, a decision must be made whether treatment other than extraction is feasible (Flores MT et al., 2007). There is no doubt that CaOH has been widely used for vital pulp therapy. The strong alkalinity of CaOH contributes to its action. It provides a bactericidal environment in which subsequent repair and hard tissue bridge can occur. Mineral trioxide aggregate (MTA) has lately been shown to be a pulp capping material,

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which produces a hard tissue barrier. It has a high sealing ability and can set in a moist environment. During the setting reaction, calcium hydroxide ions are released and high alkalinity is present in the exposed area. At present, MTA appears to be a promising candidate as an alternative to CaOH (Roberts et al., 2008). Portland cement also has a potential to be used as a less-expensive pulp capping material in comparison with MTA. It has been claimed that bioactive molecules (i.e. biological modulators that have been identified during tooth and bone embryogenesis and cloned experimentally) may provide new therapeutic tools in vital pulp therapy. Direct capping or implantation of these molecules in the pulp may stimulate the differentiation of mesenchymal cells with varying degrees of dentine bridge formation and coronal or radicular pulp mineralization. Several animal studies have reported the use of bone sialoprotein, specific amelogenin gene splice products, emdogain, dentonin, collagen products, and bone morphogenic proteins with variable degrees of success. However, further human research is required to increase the knowledge about clinical and histological effects of these bioactive molecules by implementing long-term randomized controlled trials. So far, emdogain is the only material on the market (available in gel form, Emdogain; Biora, Malmo, Sweden) that is used for direct pulp capping in human teeth with successful clinical and histological results (Kiatwateeratana et al., 2009). 2.2.4.3 Crown/root fracture When the primary tooth cannot or should not be restored, the entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth (Flores et al., 2007). In general, vertical crown-root fractures in permanent teeth must be extracted. A definitive treatment alternative for diagonal fractures is removal of the coronal fragment followed by a supragingival restoration to allow gingival healing. This procedure should be limited to superficial fractures that do not involve the pulp (i.e. chisel fracture). If the fracture is subgingival, surgical exposure of fracture surface by gingivectomy or osteotomy can convert the subgingival fracture to a supragingival one. This procedure should be limited to the palatal aspect of the fracture in order not to compromise the esthetics. If the pulp is exposed and root formation is complete,

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root canal treatment is indicated. Otherwise, pulp capping or pulpotomy is advised for the completion of root formation. Orthodontic extrusion of apical fragment to expose subgingival fracture site is used for uncomplicated crown-root fractures if pulp vitality is to be preserved. Surgical extrusion of apical fragment to expose subgingival fracture site is used when there is completed root development, and the apical fragment is long enough to accommodate a postretained crown. Fiberreinforced composite resin posts have been introduced lately as an alternative to cast or prefabricated metal posts for restoring endodontically treated teeth, because the elastic moduli of these fiber posts are closer to that of dentin than that of metal posts. Vital root submergence is indicated in young individuals as an alternative to extraction where the abovementioned treatment alternatives cannot be carried out to maintain the dimensions of the alveolar process for a future implant (Andreasen J et al., 2007). 2.2.4.4 Root fracture Treatment alternatives for primary teeth include extraction of coronal fragment without removing apical fragment or observation for spontaneous healing (Flores et al., 2007). A permanent tooth with root fracture and positive pulp sensitivity is repositioned and stabilized with a flexible splint for 4 weeks to permit pulpal healing and hard tissue repair of the fracture. If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). Pulp necrosis in root-fractured teeth is attributed to displacement of the coronal fragment and mature root development. If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth. The apical segment will usually contain vital pulp tissue, which need not be removed. The coronal segment should be treated with an interim dressing of CaOH to arrest inflammation and to stimulate apexification, which will permit adequate obturation with gutta-percha and sealer. However, CaOH dressing requires long treatment time and this application needs periodic changes of the material. Several authors have recently reported the use of MTA in root-fractured teeth as an apical plug, which has given excellent clinical results. In cases in which root fracture is close to the alveolar rest and the coronal segment is mobile, endodontic treatment can be performed on

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both segments if they are suitably aligned for instrumentation. An intraradicular splint such as stainless-steel endodontic file can then be placed and fixed with polycarboxylate cement, thus reducing the mobility of the coronal segment. This technique can be a quick remedy especially for patients who cannot make a second visit to the dental clinic. If the coronal fragment of root fracture is dislodged, it should be discarded. Orthodontic extrusion of the root is carried out after root canal therapy. Alternatively, extraction and dental prosthesis could be considered if age and other factors are favorable (Leung S et al., 2006). However, this can lead to labio-lingual collapse of the alveolar process later on. A preferred alternative treatment is submerged vital root fragment (Andreasen J et al., 2007). 2.3 Luxation 2.3.1 Classification Comparing and accumulating data from different studies is extremely difficult due to the differences in the definitions and classifications used. The WHO classification of oral trauma describes injuries to the internal structures of the mouth. Luxation injuries are grouped as one and not divided into intrusive, extrusive and lateral luxations as is the case with the Andreasen classification. Injuries to the alveolar socket and fractures of the mandible or maxilla are not grouped under oral injuries with the WHO standards, but rather are classified separately as fractures of face bones.There is a broad group incorp o r ated with the WHO standards which allows for other injuries including laceration of oral soft tissues. These types of open ended groupings may lend themselves to misinterpretation by investigators. 2.3.1.1 Concussion Concussion is defined as an injury to the tooth supporting structures without abnormal loosening or displacement of the tooth. There may be bleeding around the gingiva as a result of injury to the tooth supporting structures. Concussed teeth will be tender to percussion due to an inflamed and injured periodontal ligament. Pulp sensibility testing is likely to give positive results. Radiographic examination reveals the tooth to be in its normal position in the socket.

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The general prognosis is different between primary teeth and permanent teeth. Primary teeth, unless associated infection exists, no pulp therapy is indicated. Although there is a minimal risk for pulp necrosis, mature permanent teeth with closed apices may undergo pulp necrosis due to associated injuries to the blood vessels at the apex and, therefore, must be followed carefully. 2.3.1.2 Subluxation (loosening) Subluxation is defined as an injury to the tooth supporting structures with abnormal loosening but without tooth displacement. The diagnosis and treatment is similar to a concussion injury except for managing the increased mobility of the injured tooth. Treatment objectives are to optimize healing of the periodontal ligament and maintain pulp vitality. This is accomplished by relieving the tooth from occlusion. Splinting is usually not indicated unless the patient complains of tooth mobility. The patient should be placed on a soft diet for two weeks. 2.3.1.3 Extrusive luxation (peripheral displacement, partial avulsion) Partial displacement of the tooth out of its socket. Extruded teeth appear elongated and most often with lingual deviation of the crown, as the tooth is suspended only by the palatinal gingiva. There is always bleeding from the periodontal ligament. The percussion sound is dull. Radiographic examination always reveals increased with of the periodontal ligament space.

Figure 2.5: Pathogenesis of extrusive luxation. Oblique forces displace the tooth out of its socket. Only the palatal gingival fibers prevent the tooth from being avulsed. Both the PDL and the neurovascular supply to the pulp are ruptured.

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2.3.1.4 Lateral luxation Eccentric displacement of the tooth. This is accompanied by comminution or fracture of the alveolar socket. The crowns of laterally luxated teeth are in most cases displaced lingually and are usually associated with fractures of the vestibular part of the socket wall. Displacement of teeth after lateral luxation is normally evident by visual inspection. However, in case of marked inclination of maxillary teeth, it can be difficult to decide whether the trauma has caused minor abnormalities in tooth position. In such cases, occlusion should be checked. Due to the frequently locked position of the tooth in the alveolus, clinical findings revealed by percussion and mobility tests are identical with those found in intruded teeth. Likewise, a laterally luxated tooth shows an increased periodontal space apically when the apex is displaced labially. However, this will usually be seen only in an occlusal or eccentric exposure. An orthoradial exposure will give little or no evidence of displacement. The radiographic picture, which imitates extrusive luxation, is explained by the relation between the dislocation and direction of the central beam.

Figure 2.6: Pathogenesis of lateral luxation. Horizontal forces displace the crown palatally and the root apex facially. Apart from rupture of the PDL and the pulp neurovascular supply, compression of the PDL is seen on the palatal aspect of the root.

Primary teeth requiring repositioning have an increased risk of developing pulp necrosis compared to teeth that are left to spontaneously reposition. In mature permanent teeth with closed apices, pulp necrosis and pulp canal obliteration are common healing complications while progressive root resorption is less likely to occur.

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2.3.1.5 Intrusive luxation (central dislocation) An intrusive luxation is defined as a dislocation of the tooth deeper into the alveolar bone in an apical direction into the socket. This injury is accompanied by comminution or fracture of the alveolar socket. It is considered one of the most severe types of dental injuries to the teeth because it might cause great damage to the periodontal ligament (PDL), the pulp and the alveolar bone. Intrusive luxation in the permanent dentition is an uncommon dental injury, with a frequency of 0.51.9% of all dental injuries. Periodontal regeneration may occur in moderate intrusions, but complications like pulp necrosis, infection-related (inflammatory) root resorption, ankylosis-related resorption (replacement resorption) and marginal bone loss are frequent. Pulp canal obliteration is common but should be considered as sign of a revitalization of the pulp. Clinical findings reveal that the tooth appears to be shortened or, in severe cases, it may appear missing. The tooths apex usually is displaced labially toward or through the labial bone plate in primary teeth and driven into the alveolar process in permanent teeth. The tooth is not mobile or tender to touch. Radiographic findings reveal that the tooth appears displaced apically and the periodontal ligament space is not continuous. Determination of the relationship of an intruded primary tooth with the follicle of the succedaneous tooth is mandatory. If the apex is dis- placed labially, the apical tip can be seen radiographically with the tooth appearing shorter than its contralateral. If the apex is displaced palatally towards the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth appears elongated. An extraoral lateral radiograph also can be used to detect displacement of the apex toward or though the labial bone plate. An intruded young permanent tooth may mimic an erupting tooth. The general prognosis, in primary teeth, 90% of intruded teeth will reerupt spontaneously (either partially or completely) in 2 to 6 months. Even in cases of complete intrusion and displacement of primary teeth through the labial bone plate, a retrospective study showed the reeruption and survival of most teeth for more than 36 months. Ankylosis may occur, however, if the periodontal ligament

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of the affected tooth was severely damaged, thereby delaying or altering the eruption of the permanent successor.6 In mature perma-nent teeth with closed apices, there is considerable risk for pulp necrosis, pulp canal obliteration, and progressive root resorption. Immature permanent teeth that are allowed to reposition spontaneously demonstrate the lowest risk for healing complications. Extent of intrusion (7 mm or greater) and adjacent intruded teeth have a negative influence on healing. 2.3.2 Etiology Traumatic dental injuries (TDIs) occur with great frequency in preschool, school age children and young adults comprising 5% of all injuries for which people seek treatment. A twelve year review of the literature reports that 25% of all school children experience dental trauma and 33% of adults have experienced trauma to the permanent dentition with the majority of injuries occurring before age. Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent dentition. TDIs present a challenge to clinicians worldwide. Oral factors (increased overjet with protrusion), environmental

determinants (material deprivation) and human behaviour (risk-taking children, children being bullied, emotionally stressful conditions, obesity and

attentiondeficit, hyperactivity disorder) were found to increase the risk for TDIs. Other factors increasing the risk for TDIs are presence of illness, learning difficulties, physical limitations and inappropriate use of teeth. A new cause of TDIs that is of particular interest is oral piercing. In traffic facial injury was similar in unrestrained occupants (no seat belts) and occupants restrained only with an air bag. Amateur athletes have been found to suffer from TDIs more often than professional athletes. Falls and collisions mask intentional TDIs, such as physical abuse, assaults and torture. Violence has increased in severity during the past few decades and its role has been underestimated when looking an intentional vs unintentional TDIs. Trauma to the face or teeth can be caused by auto accidents, falls, and injury from sports such as football, hockey, soccer, volleyball, basketball, and baseball, etc. Patients suffering significant head, neck, or facial trauma should be

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evaluated and treated in hospital emergency rooms. Such trauma may involve bleeding from the nose or ears, concussion, dizziness, lapse of memory, disorientation, severe headache and earache, or breaking (fracture) of the skull and/or jaws. Most hospitals have on their staff oral surgeons who can treat fractures of the upper or lower jaw and perform emergency tooth removal (dental extractions) and reconstruction of the dental arches. Wear and tear due to cavities and chewing hard objects, such as pencils, ice cubes, nuts, and hard candies, can also lead to tooth fractures. Dental injury without associated head and neck trauma can be evaluated and treated in a dental office. Such dental injuries include broken (fractured) teeth, teeth totally knocked out of the mouth, or teeth displaced by unexpected external forces. These dental accidents may be associated with swelling of the gum and oral tissue. Cold packs or ice cubes placed either inside the mouth directly above the injured tooth, or outside on the cheeks or lips, can reduce pain and swelling before the patient reaches the dentist. 2.3.3 Manifestation 2.3.3.1 Periodontal Space Enlargement The tissues which surround the teeth, and provide the support necessary for normal function form the periodontium. The periodontium is comprised of the gingiva, periodontal ligament, alveolar bone, and cementum. Lateral surface of the root, covered by cementum and alveolar cavity, separates a small space, hourglass shape in vertical section called periodontal or alveolo-dental space. Periodontal space is occupied by beams of alveolodental ligament, forming the periodontal ligament. The round or oval areas of ligament fibers are lax connective tissue that contains numerous connective tissue cells, epithelial cell debris and network rich blood, lymphatic vessels and nerves, ligaments realize a connection between the tooth root and the alveolar bone. The fiber network also connects synergists tooth and marginal gum to their neighborhood (Mueller, 2005). Periodontal ligament consists of functionally oriented collagen fibers (primary), elastic fibers orientated vaguely anarchic (secondary) and arranged around vessels, reticulin and oxitalan fibers. The periodontal ligaments has

21

some function such as turns occlusal forces in strong pressure on alveolar bone traction and disperse them all over the compact internal pockets, maintains the tooth into the socket securely, keeps tightly applied gum tissue around the tooth package, offers protection from occlusion pressure, also protects vessels and nerves from crushing their periodontal alveolar walls by its suspension and damping systems while acting as a soft protective coating (Dumitriu, 2006). As the trauma hit the orofacial region, especially where the anterior teeth are, theres a good chance the periodontal ligaments of the involved teeth would be damaged too. There are some traumatic lesion that could make the enlargement of the periodontal space. The conditions are diagnosed with the radiographic imaging (Berman et al, 2006). When the trauma causes lateral luxation without apical displacement, the luxated tooths apex has remained in its original position. There is no widening of the periodontal space (as confirmed by observing three periapical radiographs exposed from different angulations along with one occlusal radiograph). If the trauma causes lateral luxation with apical displacement, periapical radiographic examination will most likely show a periodontal space that is widened around the midportion and coronal portion of the root, but normal or mildly compressed apically (Berman et al, 2006). In extrusions, the tooth will be loose and markedly extended out of its socket in comparison with adjacent teeth. Lateral luxations are frequently associated with extrusions. Periapical radiographs will most likely show a widened periodontal ligament space on the mesial and/or distal aspects of the root, and there may be an empty radiolucent space apically. While in intrusive luxation injury, the intruded tooth will appear as if it is not fully erupted, such that a portion or even the whole crown is submerged subgingivally. The tooth is firmly locked into the alveolar bone. A thorough radiographic evaluation of intruded teeth is necessary and will typically show complete disappearance of the periodontal space (Berman et al, 2006).

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2.3.3.2 Neurovascular Pulp The neurovascular system around the teeth and inside the pulp is the main indicators for the vitality of the teeth. Theres always a risk the teeth would become non vital if the tooth got an injury (Berman et al, 2006). The pulp of laterally luxated teeth without apical displacement may be unresponsive to cold or electrical sensitivity tests initially and during the following weeks or sometimes months. Yet, there is a good likelihood that the neurovascular bundle is intact. Meanwhile, the laterally luxated teeth with apical displacement are more likely to become non vital. If there is radiographic evidence that the apex has moved out of its normal position, then there is a very high probability that the neurovascular bundle has been compromised and the supply to the pulp could have stopped (Berman et al, 2006). An extrusive luxated tooth could have poor chance for its pulp to remain intact. Depending on how far the tooth has been extruded, the pulp may or may not respond to pulp tests. The greater the extent of the extrusive luxation, the greater the likelihood that the tooths neurovascular bundle has been severed. While on an intrusive luxated tooth, the pulp and neurovascular bundle usually could not survive anymore. As a result of the massive injury to the neurovascular bundle, intruded teeth will not respond to pulp sensitivity tests. Compromised neurovascular bundle on luxated teeth more likely making the tooth became a necrosis tissue and soon become non vital. Intrusive luxation appear as the primary cause that makes the pulp become non vital and the second one is the lateral luxation (Berman et al, 2006). 2.3.4 Management/Therapy a. Concussion No treatment is needed Monitor pulpal condition for at least one year. Follow-Up Procedures for luxated permanent teeth (4 Weeks C++ , 6-8 Weeks C++, 1 Year C++ ) b. Subluxation

23

Normally no treatment is needed, however a flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks

Follow-Up Procedures for luxated permanent teeth (2 Weeks S+, C++ , 4 Weeks C++ , 6-8 Weeks C++, 6 Months C++, 1 Year C++).

c. Extrusive Luxation Reposition the tooth by gently re-inserting It into the tooth socket. Stabilize the tooth for 2 weeks using a flexible splint. In mature teeth where pulp necrosis is anticipated or if several signs and symptoms indicate that the pulp of mature or immature teeth became necrotic, root canal reatment is indicated. Follow-Up Procedures for luxated permanent teeth (2 Weeks S+, C++, 4 Weeks C++, 6-8 Weeks C++, 6 Months C++, 1 Year C++, d. Lateral Luxation Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location. Stabilize the tooth for 4 weeks using a flexible splint. Monitor the pulpal condition. If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption. Follow-Up Procedures for luxated permanent teeth (2 Weeks S+, C++, 4 Weeks C++, 6-8 Weeks C++, 6 Months C++, 1 Year C++). e. Intrusive Luxation Teeth with incomplete root formation: allow eruption without intervention, if no movement within few weeks, initiate orthodontic repositioning, if tooth is intruded more than 7mm, reposition surgically or orthodontically. Teeth with complete root formation: allow eruption without intervention if tooth intruded less than 3mm. If no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop. If tooth is intruded beyond 7mm, reposition surgically. The pulp will likely become necrotic in teeth with complete root formation root canal therapy using a temporary filling with calcium hydroxide is recommended and treatment should begin 2-3 weeks after surgery. Once an intruded tooth has been

24

repositioned surgically or orthodontically, stabilize with a flexible splint for 4-8 weeks. Follow-Up Procedures for luxated permanent teeth (2 Weeks S+, C++, 4 Weeks C++, 6-8 Weeks C++, 6 Months C++, 1 Year C++0. 2.3.4.1 Splinting Following all types of pocket treatment, the pocket fills with blood. The fibrin net of the coagulum closely approximates the conditioned root surface. The organization of this coagulum, the formation of new periodontal structures (by periodontal ligament fibroblasts) requires several weeks. If a tooth is constantly mobile duringthis healing phase, the attachment (adhesions) to the root surface will be significantly disturbed (Wolf, et al., 2005). The demand for stabilization of the treated teeth is espec ially important after the use of regenerative techniques such as the implantation of bone and bone-replacement materials, and the GTR techniques, as well as the use of growth factors and matrix proteins, and even combinations of these methods. Additional indications are illustrated below (Wolf, et al., 2005).

Figure 2.7. Classification and indications of splinting (Wolf, et al., 2005).

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a. Temporary or semi-permanent These protect against further trauma caused by occlusal and oral parafunctions (e.g. tongue pressing, sucking). It can be used as an emergency procedure with extremely mobile teeth. It also can serve to reduce trauma-mechanical, instrumental- during periodontitis therapy (Wolf, et al., 2005).

Figure 2.8 Wire Splint (Wolf, et al., 2005).

Wire splint, soft steel wire (0,4 mm diameter) is wrapped around the facial and oral surfaces of the teeth to be splinted, and the ligature/splint is tightened by twisting the ends. Stabilization of individual teeth is accomplished by application of interdental ligatures. Acid-etch resin stops may be applied to the labial surface to prevent the wire sliding apically. The wire ligature/splint is used intra- and post-operatively, in most cases in combination with a wound dressing (Wolf, et al., 2005).

a.

b.

c.

Figure 2.9. a.Composite Resin Splint; b. Incisal view (red=etched enamel, yellow=resin); c. Etched enamel surface (Wolf, et al., 2005).

Composite Resin Splint, no tooth preparation. Following thorough cleaning of the teeth, and under the rubber dam, the proximal surfaces are acid-etched and resin is applied. The apical region must be left open for oral hygine (Wolf, et al., 2005).

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b. Semi-permanent/permanent This can enhance masticatory comfort when teeth are highly mobile; also to stabilize the teeth during periodontal healing phases, especially following regenerative therapies. Awaiting the long-term prognosis. Retention following orthodontic treatment (Wolf, et al., 2005). 1) Permanent Used for complex oral rehabilitation where abutments are highly mobile or where only few abutments must support the reconstruction, particularly when such abutment teeth have minimal periodontal support. Distribution of occlusal forces when parafunctions cannot be eliminated. In such cases, without splinting, there is a danger of progressively increasing tooth mobility and tooth migration (Wolf, et al., 2005). Patients diagnosed with increased tooth mobility may need only an occlusal equilibration and, perhaps, conventional splint therapy. Those individuals diagnosed with increasing tooth mobility must first receive periodontal therapy. Treatment should include an occlusal analysis and equilibration, if needed, followed by a reevaluation for extraction or splinting of the affected teeth (Bernal, 2002). One obvious indication for splinting is when a patient presents with multiple teeth that have become mobile as a direct result of gradual alveolar bone loss, a reduced periodontium. A second indication for splinting is when the patient presents with increased tooth mobility accompanied by pain or discomfort in the affected teeth. Splinting may be a way to gain stability, reduce or eliminate the mobility, and relieve the pain and discomfort (Bernal, 2002). The main objective of splinting is to decrease movement threedimensionally. This objective often can be met with the proper placement of a cross-arch splint. Conversely, unilateral splints that do not cross the midline tend to permit the affected teeth to rotate in a faciolingual direction about a mesio-distal linear axis (Bernal, 2002). If splinting is to achieve any measure of success, the center of rotation of the affected teeth must be located in the remaining supporting

27

bone. In this way, the affected teeth are able to resist tooth movement. Otherwise, the prognosis for any splint will be unfavorable if the occlusal or masticatory forces exceed the resistance provided by the splinted teeth (Bernal, 2002). Types of splinting: a. The Provisional Splint As the name alone implies, the objective of a provisional splint is to absorb occlusal forces and stabilize the teeth for a limited amount of time. Provisional splints can be useful adjuncts to many different types of treatment. They provide insight into whether or not stabilization of the teeth provides any benefit before any irreversible definitive treatment is even initiated. Provisional splints can either be placed externally or internally. External splints typically are fabricated using ligature wires, nightguards, interim fixed prostheses, and composite resin restorative materials. Internal splints, on the other hand, are fabricated using composite resin restorative material with or without wire or fiber inserts. Most provisional splints are made using some form of external support in their design (Bernal, 2002). Provisional splinting can also be used when treating periodontally compromised patients with conventional fixed prosthodontics. An interim restoration not only can improve esthetics, it can restore the occlusal scheme to be incorporated into any definitive prostheses. After wearing provisional splint, patients should be reevaluated to determine if treatment should proceed to a definitive restoration. Only after the interim restoration has been worn by the patient can the design and occlusal form be evaluated. This evaluation should be made before deciding to proceed with the definitive restoration.9 Any design modifications can then be made in the definitive restoration (Bernal, 2002). b. Definitive Splints Definitive splints are placed only after the completion of periodontal therapy and once occlusal stability has been achieved in order to eliminate or prevent occlusal trauma, increase functional stability, and improve esthetics on

28

a long-term basis. Such treatment includes conventional fixed prostheses because they provide definitive rigidity and are better able to control and direct occlusal forces than removable splints. For partially edentulous patients, the definitive splint of choice is a complete coverage fixed partial denture. Fixed partial dentures not only stabilize the affected teeth, but they also improve esthetics and may even prevent further tooth loss (Bernal, 2002). The single observation of tooth mobility is not unto itself sufficient justification to splint teeth. Tooth mobility alone does not necessarily indicate the existence of an underlying pathologic condition. Splinting is best viewed as a preventive treatment measure for teeth that have minimal or no bone loss, yet are clinically mobile. Splinting affords no guarantee that occlusal stress can be completely eliminated (Bernal, 2002). Although extraction is an appropriate treatment for extremely mobile teeth, it may not resolve all the underlying pathology if the etiology of that mobility is not established first. Before treatment is started, it is recommended the cause of any mobility be identified to determine if it is related to an occlusal discrepancy. It may be that an occlusal equilibration and splinting (provisional or definitive) may actually prevent tooth loss and restore both patient comfort and function (Bernal, 2002). Splinting teeth to each other allows weakened teeth to gain support from neighbouring ones. When used to connect periodontally compromised teeth, splinting can increase patient comfort during chewing. Connecting multiple teeth also increases support when the teeth are used as abutments for a precision attached partial denture. However, splinting makes oral hygiene procedures difficult. Therefore, to ensure the longevity of the connected teeth, special attention must be given to instructing the patient about enhanced measures for oral hygiene after placement of the prosthesis (Barzilay, 2000). Several methods, both extracoronal and intracoronal, are available to splint teeth together (Barzilay, 2000). c. Extracoronal Splinting The simplest way to connect teeth to each other is the classic bonding method. The enamel surface of the tooth is etched, most commonly with a

29

37% solution of phosphoric acid. Composite resin can then be bonded to the etched surface and used to rigidly connect the teeth to each other. The composite-resin splint can be strengthened by adding fibres to the splint or by using a fibre meshwork (e.g., Ribbond, Ribbond Inc., Seattle, WA) to reinforce the material (Barzilay, 2000). Extracoronal resin-bonded retainers, which can be fabricated in the dental laboratory, serve to strengthen the overall bonded situation. The splints are usually cast from metals, usually non- noble alloys that can be electrolytically or chemically etched (Barzilay, 2000). d. Intracoronal Splinting Intracoronal methods are also available. Composite-resin restorations can be placed in adjoining teeth and cured to eliminate any interproximal separation. These restorations can be further reinforced with metal wires, glass-reinforced fibres or pins. If restoration of the mouth includes crowns, the crowns can be splinted to each other by solder joints or precision attachments. The use of attachments affords the practitioner the ease of preparing nonparallel abutments yet achieves a splinted result (Barzilay, 2000). 2.3.4.1.1 Arch bar splint Arch bar splints were first introduced by hammond in 1870s as splints for maxillary and mandibular fractures.They consist of a metal arch bar bent in to the shape of an arch which is secured in place with ligature wires. The main disadvantage of this type of splint is that it is rigid and hence its use, in the case of dental injuries, is limited.In addition, where the arch bar is not bent in to correct shape, it can exert orthodontic forces on the tooth.It has also been noted that arch bar splints can become loose and rest on marginal gingivae causing mechanical irritation (Bernal, 2002).

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Figure 2.10: Arch bar illustration

Figure 2.11: Arch bar splint

Bent metal arch bars attached to the teeth with separate ligatures are still used for the lixation of mandibular and maxillary fractures and similar arch bars have also been used for luxated teeth. The first arch bar as we know it today was developed by a London dentist, Hammond, in the 1870s. He used a cast ofthe dentition to bend the arch. The arch bar has been modified for tooth luxation cases by adding incisal notches to it. Which ensures that the luxated teeth catmot move upwards when the ligatures are tightened (or downwards in the upper dentition) (Lagvangkar, 1990). A method to tighten th e arch bar by a special loop in its distal parts was introduced by Lagvankar. The difiiculty with th e use of arch bars is that they must be bent exactly along the dental arch, because incompletely bent arches may have an orthodontic eflect on the fixed teeth. The fact thtit the arch bar splint loosens with time and rests on the marginal gingiva, causing mechanical irritation and bacterial deposition, does not make it

recommendable lor tooth fixation (Lagvangkar, 1990). Schuchardt developed an arch bar covered with self-cured acryl for the fixation of jaw bones. This Schuchardt splint is bent on a model, or directly on the dental arch, and ligated around the teeth with wires and covered with

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acrylic. It is still used to maintain intermaxillary fixation in orthognathic surgery and for the fixation of jawbone fractures (90). A modification ofthe Schuchardt splint, the 'luxation splint', has been used for the fixation of luxated teeth, but is regarded at present as too rigid and too complicated to construct for this purpose. An arch bar fixed by etching technique on labial surfaces was introduced by Booth and Collins (Booth & Collins , 1990). 2.4 Avultion 2.4.1 Definition Dental avulsion is the complete displacement of a tooth from its socket in alveolar bone owing to trauma (Zadik and lavin, 2009). The treatment consists of replantation, immediately if possible. Immediate replantation ensures the best possible prognosis but is not always possible since more serious injuries may be present. Studies have shown that teeth that are protected in a physiologically ideal media can be replanted within 15 minutes to one hour after the accident with good prognosis. The success of delayed replantation depends on the vitality of the cells remaining on the root surface. In normal conditions, a tooth is connected to the socket by means of the periodontal ligament. When a tooth is knocked-out, that ligament stretches and splits in half (Krasner, 1995). Maintaining the vitality of the cells that remain attached to the root surface is the key to success following replantation. Years ago, it was thought that the key to maintaining root cell vitality was keeping the knocked-out tooth wet (Andreasen, 1970) thus giving rise to storage media recommendations such as water, the mouth and milk. Recent research has shown that one of the key elements for maintaining vitality is storing the tooth in an environment that closely resembles the original socket environment. This environment is one that has the

proper osmolality (cell pressure), pH, nutritional metabolites and glucose. There are scientifically designed storage media that provide this environment. These storage media are now available to the consumer in retail products. Use of devices that incorporate the ideal storage media and protective apparatuses have increased the success rate of replanted knocked-out teeth to over 90% when used within sixty minutes of the accident.

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The best method for the prevention of knocked-out teeth is the use of helmets and mouth protectors. Mouth protectors can be very inexpensive, however, the compliance rate for their use is poor (Zadik et al., 2010). Studies have shown that, even when mandated, athletes and other high risk individuals often will not use them (Zadik, 2008). Also, even with their use, mouth guards can be knocked-out, leaving the user unprotected. 2.4.2 Epidemiology Research has shown that there are five million teeth knocked-out each year up to 25% of school-aged children and military trainees and fighters experience some kind of dental trauma each year (Zadik and Lavin, 2009). The incidence of dental avulsion in school aged children ranges from 0.5 to 16% of all dental trauma. Many of these teeth are knocked-out during school

activities or sporting events and hockey.

such

as contact

sports, football, basketball,

In 1959, Lenstrup and Skieller declared that the success rate of replanted knocked out teeth should be considered a temporary procedure because the success rate of less than 10% was so poor. In 1966 in a retrospective study, Andresen theorized that 90% of avulsed teeth could be successfully retained if they were replanted within the first 30 minutes of the accident. In 1974, Cvek showed that storage of knocked out teeth in saline could improve the success of replanted teeth. In 1980, Blomlof showed the storing the periodontal ligament cells in a biocompatible medium could extend the extra oral time to four hours or more. He found that the best storage medium was a medical research fluid called Hanks Balanced Solution. In this study, it was serendipitously discovered that milk could also maintain cell viability for two hours. In 1981, Andreasen showed that crushing of cells on the tooth root could cause death of the cells and lead to resorption and reduction in prognosis. In 1983, Matsson et al. showed that soaking in Hanks Balanced Solution for thirty minutes prior to reimplantation could revitalize extracted dogs teeth that were dry for 60 minutes. In 1992, Trope et al. showed that extracted dogs teeth could be stored in Hanks Balanced Solution for up to 96 hours and still maintain significant vitality. In this study, milk was only able to maintain vitality for two hours.

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2.4.3 Management/Therapy Treatment guidelines for avulsed permanent teeth (Flores, 2007) a. Tooth with a closed apex. 1) The tooth has already been replanted. 2) The tooth has been kept in special storage media (Hanks Balanced Salt Solution), milk, saline, or saliva. The extra-oral dry time is less than 60 min. 3) Extra-oral dry time longer than 60 min. b. Tooth with open apex. 1) The tooth has already been replanted. 2) The tooth has been kept in special storage media (Hanks Balanced Salt Solution), milk, saline, or saliva. The extra-oral dry time is less than 60 min. 3) Extra-oral dry time longer than 60 min.
Table 2.2: Treatment guidelines for avulsed permanent teeth with closed apex (Flores, 2007)

Clinical situation (1a) The tooth has been replanted prior to the patient arriving at the dental office or clinic

Treatment Clean the area with water spray, saline, or

chlorhexidine. Do not extract the tooth. Suture gingival lacerations ifpresent. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients PhenoxymethylPenicillin (Pen V), in an appropriate dose for age and weight, can be given as alternative to tetracycline. If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer to physician for evaluation and need for a tetanus booster. Initiate root canal treatment 710 days after replantation and before

34

splint removal. Place calcium hydroxide as an intracanal medicament until filling of the root canal. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. (1b) The tooth has been kept in special storage media (Hanks Balanced Salt Solution), milk, saline, or saliva. The extraoral dry time is less than 60 min If contaminated, clean the root surface and apical foramen with a stream of saline and place the tooth insaline. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there isa fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V), at appropriate dose for age and weight, can be given as alternative to tetracycline. If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer the patient to a physician for evaluation and need for a tetanus booster. Initiate root canal treatment 710 days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal.

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Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. (1c) Extra-oral dry time longer than 60 min Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation is to promote alveolar bone growth to encapsulate the replanted tooth. The expected eventual outcome is ankylosis and resorption of the root. In children below the age of 15, if ankylosis occurs, and when the infraposition of the tooth crown is more than 1 mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge. The technique for delayed replantation is: Remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation, or it can be done 710 days later as for other replantations. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Immerse the tooth in a 2% sodium fluoride solution for 20 min Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically Stabilize the tooth for 4 weeks using a flexible splint. Administration of systemic antibiotics, see (1a). Refer to physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus

36

coverage is uncertain. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. 2.4.3.1 Follow-up procedures for avulsed permanent teeth a. Root canal treatment If root canal treatment is indicated (teeth with closed apex), the ideal time to begin treatment is 710 days postreplantation. Calcium hydroxide isrecommended for intra-canal medication for up to 1 month followed by root canal filling with an acceptable material. An exception is a tooth that has beendry for more than 60 min before replantation in such cases the root canal treatment may be done prior to replantation.In teeth with open apexes, that have been replanted immediately or kept in appropriate storage media, pulp revascularization is possible. Root canal

treatmentshould be avoided unless there is clinical and radiographic evidence of pulp necrosis(Flores, 2007). b. Clinical control Replanted teeth should be monitored by frequent controls during the first year (once a week during the months 1, 3, 6, and 12) and then yearly thereafter.Clinical and radiographic examination will provide information to determine outcome. Evaluation may include the findings described as follows(Flores, 2007). c. Favorable outcome (1) Closed apex. Asymptomatic, normal mobility, normal percussion sound. No radiographic evidence of resorption or periradicularosteitis; the lamina durashould appear normal(Flores, 2007). (2) Open apex. Asymptomatic, normal mobility, normal percussion sound.Radiographic evidence of arrested or continued root formation and eruption. Pulpcanal obliteration is the rule(Flores, 2007).

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d. Unfavorable outcome (1) Closed apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound.Radiographic

evidence of resorption(inflammatory, infection-related resorption, or ankylosis-related replacement resorption)(Flores, 2007). (2) Open apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. In the case of ankylosis, the crown of thetooth will appear to be in an infra-occlusal position. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-relatedreplacement

resorption) (Flores, 2007). 2.4.3.2 Splinting guidelines for avulsed teeth Replanted permanent teeth should be splinted up to 2 weeks. Wirecomposite splint has been widely used to stabilize avulsed teeth because it allows good oral hygiene and are well tolerated by the patients (Flores, 2007).

Figure 2.12: The tooth was repositioned and stabilized with a flexible wire-composite splint. The splint is
extended to the primary canines because of the absence of adjacent teeth during early mixed dentition (Flores, 2007).

2.4.3.3 Endodontic Treatment Extra oral time < 60 min a. Closed Apex Initiate endodontic treatment at 7 to 10 days. In cases where endodontic treatment is delayed or signs of resorptionare present, treat with long-term calcium hydroxide treatment before obturation (Trope, 2002). No chance exists for the revascularization of these teeth, and endodontic treatment should be initiated at the second visit at 710days.If therapy is initiated at this optimum time, the pulp should be necrotic without

38

infection or, at most, only minimal infection. Therefore, endodontic therapy with an effective interappointment antibacterial agent over a relatively short period of time (710 days) is sufficient to ensure effective disinfection of the canal. If the dentist is confident of complete patient cooperation, long-term therapy with calcium hydroxide remains an excellent treatment method. The advantage of its use is that it allows the dentist to have a temporary obturating material in place until an intact periodontal ligament space is confirmed. Long-term calcium hydroxide treatment should always be used when the injury occurred more than 2 weeks before the start of endodontic treatment or if radiographic evidence of resorption is present (Trope, 2002). The root canal is thoroughly instrumented and irrigated, then filled with a thick, powdery mix of calcium hydroxide and sterile saline (anesthetic solution is also an acceptable vehicle). The calcium hydroxide is changed every 3 months within a range of 624 months. The canal is obturated when a radiographically (fig. 2.13). A. Active resorption can be seen soon after the tooth was replanted. B. After long-term Ca (OH)2 treatment, the resorptive defects have healed, and an intact lamina dura can be traced around the root. The tooth is ready for obturation. Radiographically intact periodontal membrane can be demonstratedaround the root. Calcium hydroxide is an effective antibacterial agent, and favorably influences the local environment at the resorption site, theoretically promoting healing. It also changes the environment in the dentin to a more alkaline pH, which may slow the action of the resorptive cells and promote hard tissue formation. However, the changing of the calcium hydroxide should be kept to a minimum (not more than every 3 months) because it has a necrotizing effect on the cells that are attempting to repopulate the damaged root surface (Trope, 2002).

39

Figure 2.13: A. Active resorption can be seen soon after the tooth was replanted. B. After longterm Ca (OH)2 treatment, the resorptivedefects have healed, and an intact lamina dura can be traced around the root. The tooth is ready for obturation (Trope, 2002).

While calcium hydroxide is considered the drug ofchoice in the prevention and treatment of inflammatory root resorption, it is not the only medicament recommended in these cases. Some attempts have been made to not only remove the stimulus for the resorbing cells but also to affect them directly. The antibioticcorticosteroid paste, Ledermix, is effective in treating inflammatory root resorption by inhibiting the spread of dentinoclasts without damaging the periodontal ligament. Its ability to diffuse through human tooth roots has been demonstrated, whilst its release and diffusion is further enhanced when used in combination with calcium hydroxide paste. Calcitonin, a hormone that inhibits osteoclasticbone resorption, is also an effective medication in the treatment of inflammatory root resorption (Trope, 2002).

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CHAPTER 3 CONCEPTUAL MAPPING

CONCEPT MAPPING

22 years old male Traumatic anterior teeth

Radiolucent line on interdental (11-21)

Loosing teeth, disposition, bleeding

Edentulous 11 tooth

Soft Tissue damage

Swelling and sore lips (1cm, irregular)

Alveolar fracture (interdental) Periodontal trauma

Luxation

Avulsion (11)

Traumatic oral ulceration on lower labial region

Disruption of neurovascular supply Ischemia

Vitality test (-)

Increase periodontal space

Non-vital teeth (21, 22) Therapy

Tx 1: Corticosteroid, Antibiotic

Tx 3: Splinting - TTS

Tx 4: Endodontic treatment PSA

Tx 2: Replantation and Endodontic

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Concept mapping explanation: In the case explained that the 22 -year -old man suffered a motorcycle accident trauma. Clinical examination found 11 loose teeth, loosing teeth, disposition accompanied by bleeding of teeth 12, 21, and 22. Lower lip swollen and contained 1 cm irregular ulcer that cause pain. Ulcer is a loss to the mucous membrane of connective tissue which in this case caused by trauma from external hard object collision or as a result of being bitten. Pain caused by tissue damage that stimulates secretion of inflammatory mediators such as histamine, bradykinin, serotonin, leukotrienes, and prostaglandins to the injury area. Soft tissue damage will result in disintegration and loss of connective tissue to form ulcers. Traumatic ulceration can be treat by clean the wound with antiseptic and use topical medications such as corticosteroids. On intra oral examination to test the vitality of teeth 21 and 22 did not respond. Investigations radiolucent radiographic obtained in the region of missing teeth - edentulous (11), widening of the periodontal space on teeth 12, 21, and 22, and radiolucent lines on interdental region of alveolar bone between 21 and 11. Of the examination result can be known that due alveolar fracture on interdental region but not until a displacement so that no special treatment is needed, the avulsed tooth 11 tooth losses due to trauma from its socket. Avulsed tooth can be treat by replantation. Teeth 12, 21, and 22 had luxations that cause tooth movement due to trauma resulting in tissue damage, leading to widening of the periodontal space, disposition of the teeth, and the breaking of the pulp vascularization. The absence of dental tissue vascularization resulting in ischemia and ultimately non - vital tooth, so the vitality test result was negative. Treatment on teeth that had luxations can be repositioned up to get the original occlusion was then fixed using flexible or semi-rigid splinting like titanium trauma splint (TTS). Intended use of the arch bar is to maintain occlusion of teeth that do not change during the formation of the fibroblasts as speaking and chewing activity. After the formation of fibroblasts for several weeks ( 2 weeks), the supporting tissues of teeth will begin to stabilize and can be treated in a non - vital teeth (11, 21 and 22), which is the root canal treatment to prevent the occurrence of pulp necrotic that can lead to apical infection or abscess.

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CHAPTER 4 DISCUSSION Issue : A 22 years old male came to the RSGM-P clinic of Airlangga University, complaints of swelling and sores lips caused by a motorcycle accident one day earlier. The right upper incisor tooth detached and three upper left and right front teeth was looses, changing the position accompanied by bleeding. Detached tooth carried by the patient and he could open and close his mouth properly. Discussion: In the case of accidents involving trauma to the head and neck, including the teeth and oral cavity, the first thing should be done is checking the state of patient to the health service or clinic nearby. But in this case, the patient just come the next day at listless state, no systemic disease, in normal temperature, 120/80 mmHg of blood pressure, and has no medicine treatment yet. A time factor could influence the treatment choice. This time factor becomes critical in the case of avulsed or displaced teem. On the first visit, the clinical examination should first include examination of soft tissue wounds. If present, the penetrating nature of these soft tissue should be determined, with emphasis on the possible presence of foreign bodies embedded within these wounds. Thereafter, hard dental tissues are examined for the presence of infractions and fractures. Clinical examination begins with an extraoral examination to rule out injuries to the facial bones. The facial structures should be palpated to determine discontinuities of facial bones. Mandibular function during excursive movements is checked. The radiographic examination follows the clinical examination. Radiographs allow for detection of root fractures, intrusions, extent of root development, pulp chamber size, periapical radiolucencies, root resorption, degree of tooth displacement, unerupted tooth position, jaw fractures, and the presence of tooth fragments. The diagnosis of infractions is facilitated by directing the light beam parallel to the labial surface of the injured tooth. The bisecting angle radiographic technique is more useful than an occlusal exposure in revealing displacement tooth, interdental alveolar fracture

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and state of tissue around the avulsed tooth socket can also be observed. The results of this radiographic examination, patient has apparent widening of the 22, 21, 12 periodontal ligament space, 11 socket radiolucency indicates odontolous, and a radiolucent line at 21 and 11 interdental. From anamnesis, we know that patient has swelling and sores lips, so the clinical examination should have determined the area of injury that is the area to be examined radiographically. In the presence of a penetrating lip lesion as soft tissue radiograph is indicated in order to locate eventual foreign bodies. It should be noted that the orbicularis oris muscles close tightly around foreign bodies in the lip, making them impossible to palpate; they can only be identified radiographically. This is accomplished by placing a dental film between the lips and the dental arch and using 25% of the normal exposure time. The impacted foreign bodies cannot be adequately removed by scrubbing or washing, but should be removed with a small excavator surgical blade kept perpendicular to the direction of the abrasion. The patient has a 1 cm irregular ulcer. Any type of damage or injury to the mouth, for instance, when the inside of the cheek or labial mucosa is accidentally bitten or scraped by jagged teeth, can cause blisters (vesicles or bullae) or ulcers to form in the mouth. Typically, the surface of a blister breaks down quickly (ruptures), forming an ulcer. This might happen to the patient in this case. An ulcer is a hole that forms in the lining of the mouth when the top layer of cells breaks down. Many ulcers appear red, but some are white because of dead cells and food debris inside the center portion. Acute ulcers show a loss of surface epithelium that is replaced by a fibrin network containing predominantly neutrophils. The ulcer base contains dilated capillaries and, with time, granulation tissue. Regeneration of the epithelium begins at the ulcer margins, with proliferating cells moving over the granulation tissue base and under the fibrin clot. Ulcers related to trauma usually resolve in about a week after removal of the cause and with the use of an anti-inflammatory and anesthetic throat spray to provide symptomatic relief and chlorhexidine 0.2% aqueous mouthwash to maintain good oral hygiene. A 2-week observation period is warranted. If pain is

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considerable, topical treatment may be of benefit. This could be in the form of a topical corticosteroid. A high potency topical corticosteroid gel, such as fluocinonide 0.05% or clobetasol 0.05% should also be prescribed and applied three to four times daily. Non-responsive lesions can be treated with a 7 10-day course of high dose prednisone. If still refractory, lesions should be considered for surgical excision, in some cases the inflammation is so deep and established that tissue debridement and primary wound closure is required, and referral to a specialist is recommended. On the same visit, dentist can do the other treatment for the main complaint. In this case, the avulsed tooth occurs by a hard dental trauma effecting tooth out from its socket and fracture mandible in part of interdental. The situation become difficult because of need for emergency care to improve the prognosis. Replantation is the first treatment choice due to avulsed tooth. Teeth should be taken in moist environment to maintain the viability of the periodontal ligament torn. The most convenient means available is the patient's mouth where teeth can be soaked in saliva at body temperature. Some studies have shown that the time outside the mouth for teeth apart, the optimum may never be exceeded 30 minutes, the teeth should be immediately taken to the doctor. And some studies say that replantation can be delayed. Procedure due delayed replantation is remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation, or it can be done 7 10 days later as for other replantation. The sooner the replantation applied on avulsion tooth, the better prognosis will be reached as long as the term and procedure has been done according to the standard operational procedure, which are asepsis, possible tissue condition, etc. The first treatment for replantation is removed the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Immerse the tooth in a 2% sodium fluoride solution for 20 minutes. Replant the tooth slowly with slight digital pressure and suture gingival laceration. After repositioning tooth, a slightly flexible splint should be applied, such as an acid-etch retained splint of temporary crown and bridge material. Unless other injuries require longer splinting periods

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(e.g., alveolar fracture), the splint should be removed after 7 days to allow some functional movement of the replant in order to reduce or eliminate the risk of ankylosis. After we do all of the following procedure we must verify normal position of the replanted tooth and evaluate the condition of teeth from radiographic photo. The patient must have soft diet for 2 weeks. The gingival attachment is re-established 7 days after injury, including splicing of the ruptured gingival fibers. Intra alveolar periodontal ligament revascularization is also complete and splicing of periodontal ligament fibers initiated 1 week after injury. After 2 weeks, periodontal ligament repair is so advanced that the periodontium has regained about two-thirds of its original strength. In teeth with complete root formation (i.e. the diameter of the apical foramen is less than 1.0 mm), the pulp should be extirpated and the root canal dressed with pure calcium hydroxide immediately prior to splint removal. When trauma happened, the magnitude of occlusal forces increased and the periodontium responds with an increase in the number and width of periodontal ligament fibers that cause widening of the periodontal ligament space. Periodontal ligament space can cause the tooth loose and tooth movement. The movement of tooth called luxation, in this case it is extrusive luxation type. It is happened when oblique forces displace 22, 21, and 12 teeth out of its socket. Only the palatal gingival fibers prevent teeth from being avulsed. Both the periodontal ligament and the neurovascular supply to the pulp are ruptured. Impact trauma may squash the blood vessels at the apical teeth and cause temporary disruption of blood flow and result in severing of the apical blood vessels. The patient is 22 years old indicate that the apical foramen is completely closed, so the probability of successful revascularization is so small. In teeth with fully developed roots, these blood vessels will often not be able to heal and revascularize the pulp. If the revascularization fails, the pulp tissue become ischemic and will undergo sterile necrosis. From vitality test also there is no response that indicating a lack of pulpa response. So we can conclude that the teeth are non vital. The first concern in the treatment of luxation injuries should be the repair of the periodontium. Soft tissue injuries and repositioning should be treated before

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endodontic procedures are contemplated. The teeth subjected to trauma should be splinted after repositioning of the tooth to prevent displacement and further injury to the pulp or the periodontal ligament during the healing phase. The tooth was brought into a position by applying careful and very gentle force incisally, repositioned to a level such that the cementoenamel junction (CEJ) was in plane with the free gingival margin. After bringing the teeth into their respective positions, these teeth were splinted. Splints are used to stabilise teeth loosened in their sockets and fractures of the alveolus and fractures of facial bones. Splinting is ideally provided directly by joining adjacent teeth together with an adhesive restorative material (such as glass-ionomer cement or bonded composite), or a piece of wire (for example orthodontic wire) retained on the teeth by an adhesive restorative material or orthodontic brackets. Other techniques such as the use of interdental or eyelet wires have been described, though these may be traumatic to the gingival tissues and may extrude a tooth if inappropriately applied. Teeth may also be splinted with a removable appliance constructed on a cast. In this case, we are using a slightly flexible splint that allows optimal oral hygiene and function of the tooth. Recommended splinting times are up to four weeks for lateral luxation injuries with alveolar fractures. Beside that, the splint is neither too rigid nor placed for too long as both these will increase the risk of ankylosis. Follow-up treatment should be do for 5 years to detect late root resorption. Trauma splints should stabilize the traumatized tooth in the original position and bring about adequate fixation for the whole immobilization period. On the other hand, the splint should be flexible enough to functionally stimulate periodontal healing. Dental trauma splints should be passive and exert no orthodontic forces. They should neither damage the gingival tissues nor increase the risk of caries. Further, the splints should not affect hygienic and aesthetic demands of the patient or interfere with occlusion. With all these requirements in mind, we choose Titanium Trauma Splint (TTS) as the best splinting treatment to be applied. This method specifically designed for fixation of traumatized teeth. This method also can be quickly applied and removed with little or no assistance. The time-consuming procedures of wire bending and stabilization during

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placement are avoided. The practitioner and the patient alike will benefit from shorter chair time and less stressful procedures reflected by the shorter working times for the TTS method. While the pulp testing result is negative, it imply that a pulp has become necrotic. The patient apical maturation is complete, so the standard endodontic treatment is indicated. The treatment for this case is multi visit root canal treatment. The purpose of root canal treatment is either to maintain asepsis of the root canal system or to disinfect it adequately. Endodontic treatment of traumatized teeth with subsequent pulp necrosis also consists of the prevention and treatment of periradicular periodontitis and external inflammatory root resorption. The first step to do is opening access. The purpose of this step is to remove the roof of the pulp chamber so that this chamber can be cleaned and good visibility of the canal orifices can be obtained, enable root canal instruments to be introduced into the root canals without undue bending, offer sufficient retention for a temporary restoration and conserve as much sound tooth tissue as possible that is compatible with the above. After that, we must determining the working length to enable the root canal to be prepared as close to the apical constriction as possible. The recommended methods to determining the working length is with radiographic. The root canal system must be prepare to remove remaining pulp tissue, eliminate microorganisms, remove debris and shape the root canal(s) so that the root canal system can be cleaned and filled. Preparation should be undertaken with copious irrigation. The objectives of irrigation are to eliminate microorganisms, flush out debris, lubricate root canal instruments and dissolve organic debris. The irrigant solution should preferably have disinfectant and organic debris dissolving properties, whilst not irritating the periradicular tissues. The irrigant solution should be delivered in copious amounts as far up the canal as possible without risking extrusion beyond the foramen. This can be performed with a syringe, ensuring that the solution is allowed to escape freely into the pulp chamber and is not delivered with excessive force. The solution may also be delivered by ultrasonic or sonic systems. The solution for irrigation we can use

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sodium hypochlorite (NaOCl). A variety of concentrations of sodium hypochlorite (0.5% to 5%) are advocated. Higher concentrations act more quickly, although the risk of tissue irritation, if the irrigant is extruded past the apex and into the periradicular tissues, is greater. Lower concentrations are also antibacterial, and are less irritant to tissues, but require longer contact times and greater volumes. We also do filling of the root canal system to prevent the passage of microorganisms and fluid along the root canal and to fill the whole canal system, not only to block the apical foramina but also the dentinal tubules and accessory canals. Materials used to fill the root canal system should be biocompatible, dimensionally stable, able to seal, unaffected by tissue fluids and insoluble, nonsupportive of bacterial growth, radiopaque, and removable from the canal if retreatment needed. The root canal filling should consist of a semisolid material in combination with a root canal sealer to fill the voids between the semisolid material and root canal wall. Sealers containing organic materials such as aldehydes are not recommended. Filling should be undertaken after the completion of root canal preparation and when the infection is considered to have been eliminated and the canal can be dried. For root canal filing we can use powdery mix of calcium hydroxide and sterile saline (anesthetic solution is also an acceptable vehicle). In some cases it might be recommended that prior to filling, the completion of root canal preparation is verified by taking a radiograph with the root canal instrument (or filling cones) inserted to the full working length. The end-point of the inserted instrument (or cone) and the apex should be visible on this verification radiograph. The quality of filling should be checked with a radiograph. This radiograph should show the root apex with preferably at least 23 mm of the periapical region clearly identifiable. The prepared root canal should be filled completely unless space is needed for a post. The prepared and filled canal should contain the original canal. No space between canal filling and canal wall should be seen. There should be no canal space visible beyond the endpoint of the root canal filling. The tooth should be adequately restored after root canal filling to prevent bacterial recontamination of the root canal system.

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An opening is made through the crown of the tooth. The pulp is removed, and then the root is cleaned and shaped. Medication may be added to the pulp chamber and root canal to help eliminate bacteria. A temporary filling is placed in the crown opening to keep saliva out. Antibiotics may be prescribed if an infection is present and has spread beyond the end of the root. On the next visit, The temporary filling is removed. After that, the root canal is filled and permanently sealed. Root canal treatment should be assessed at least after 1 year and subsequently as required. The following findings indicate a favourable outcome like absence of pain, swelling and other symptoms, no sinus tract, no loss of function and radiological evidence of a normal periodontal ligament space around the root. Another radiographic examination indicates radiolucency line at 21 and 11 interdental means there is an interdental fracture. The treatment is just allowed and through the process of healing from the body itself and does not need professional treatment, because fracture with displacement does not occur (there is only show a radiolucent line, not a radiolucent area at interdental). The healing process of this fracture starts when the cells of the periosteum replicate and transform. The periosteal cells closest to the fracture gap develop into chondroblasts which form hyaline cartilage. The periosteal cells distal to (further from) the fracture gap develop into osteoblasts which form woven bone. The fibroblasts within the granulation tissue develop into chondroblasts which also form hyaline cartilage. These two new tissues grow in size until they unite with their counterparts from other parts of the fracture. These processes culminate in a new mass of heterogeneous tissue which is known as the fracture callus. Eventually, the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength. The next phase is the replacement of the hyaline cartilage and woven bone with lamellar bone. The replacement process is known as endochondral ossification with respect to the hyaline cartilage and bony substitution with respect to the woven bone. Substitution of the woven bone with lamellar bone precedes the substitution of the hyaline cartilage with lamellar bone. The lamellar bone begins forming soon after the collagen matrix of either tissue becomes

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mineralized. At this point, the mineralized matrix is penetrated by channels, each containing a microvessel and numerous osteoblasts. The osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. This new lamellar bone is in the form of trabecular bone. Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabecular bone, restoring most of the bone's original strength. The remodeling process substitutes the trabecular bone with compact bone. The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a Howship's lacuna. Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength.

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CHAPTER 5 CONCLUSSION 5.1 Conclussion Successful treatment of patients is determined by the dentist how to choose and consider the proper treatment and care should be prioritized. Treatment stages must be ordered in advance will be made according to priorities. Before starting treatment, the dentist should examine the patient. The examination consisted of anamnesis, clinical examination, radiological, or other investigations that can establish the diagnosis. After doing correct examination and diagnosis, then the dentist should determine the appropriate treatment and drugs based on priority so that the patient can recover and can work as it should. In this case, beside anamnesis, diagnosis must be established by radiology and clinical examination, and then treatment is implemented. First treatment is for ulceration of the mouth which is exposed to traumatic ulceration using topical corticosteroids in the form of a cream or gel to relieve inflammation. Second treatment is avulsion tooth replantation. Third therapy is splinting by arch bar to recover enlargement of periodontal tissue and recover alveolar bone fracture. Then the last therapy is endodontic treatment for non-vital tooth.

5.2 Sugestion Dentist should consider the appropriate treatment in patients and consider the priority of therapy that will be given in order to successful therapy.

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